June 10, Dear Dr. Berwick:

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1 Donald Berwick, M.D., M.P.P. Administrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W., Room 445-G Washington, DC RE: CMS-1518-P, Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates; Proposed Rule (Vol. 76, No. 87), May 5, 2011 Dear Dr. Berwick: On behalf of its member hospitals, the Michigan Health & Hospital Association (MHA) appreciates this opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) regarding the proposed rule to update the hospital Inpatient Prospective Payment System (IPPS) for Fiscal Year (FY) We oppose the CMS 3.15 percent coding and documentation reduction, which is projected to decrease Medicare inpatient payments to Michigan s IPPS hospitals by $141 million in FY 2012 as unwarranted and without valid supporting data. In addition, we are concerned about other policy changes proposed in the rule that would undermine several fundamental payment principles and further reduce inadequate Medicare reimbursement nationally at a time when the population is aging and increasing their need for healthcare services. The adequacy of Medicare payments to cover the cost of services provided is vital for ensuring the future viability of Michigan s nonprofit hospitals. Medicare represents approximately 45 percent of inpatient discharges and statewide generated a nominal 0.3 percent margin in 2008 based on Medicare allowable cost. Trended forwarded with cost increases that exceeded the Medicare market basket updates, these margins evaporated in Implementing changes proposed in the FY 2011 rule will further compromise the financial stability of Michigan s hospitals and their ability to provide necessary services within their communities. Michigan s population continues to age, with approximately 17 percent currently covered by Medicare, and the number of Medicare beneficiaries projected to increase over the next decade.

2 Page 2 of 15 Coupled with a 16 percent negative margin on Medicare outpatient services, the Medicare service line is unsustainable as a business model long-term for Michigan s hospitals as the overall Medicare margin was negative 4.7 percent with 52 percent of Michigan s hospitals losing money providing Medicare services. When all payors are aggregated, Michigan hospitals experienced a negative 2.6 percent patient margin, with approximately 67 percent, losing money on patient care services. With Medicare and Medicaid comprising over 50 percent of statewide volume and both paying significantly less than cost, coupled with increasing levels of uncompensated care, hospitals are struggling to remain financially viable. The proposed Medicare changes will further threaten the future viability of hospitals and access to healthcare services for Medicare beneficiaries and other residents of the state of Michigan. Our key concerns regarding the FY 2012 proposed rule are discussed below. MS-DRG DOCUMENTATION AND CODING ADJUSTMENT The proposed rule includes a continuation of the 2.9 percent recoupment cut from FY 2011, as well as a 3.15 percent permanent cut to eliminate what the CMS claims to be the effect of documentation and coding changes that the CMS believes do not reflect real changes in casemix. Analyses conducted by the American Hospital Association (AHA) found that much smaller documentation and coding adjustments are necessary than what the CMS has implemented in the past and proposed for the future. These analyses indicate that much of the change is actually the continuation of increases in the patient acuity, not the result of documentation and coding changes due to the implementation of the Medicare severity diagnosis-related groups (MS-DRGs). As a result, the MHA believes the CMS proposed cut is excessive in light of these historical trends in CMI change and should not be implemented. Consistent with the AHA and others, the MHA believes there is a fundamental flaw in the CMS methodology for determining the effect of documentation and coding changes on the FYs 2008 and 2009 CMIs. Specifically, in its analysis, the CMS states that the increase in payments it found could not be due to real case mix change because its analysis looks at only one year of patient claims. However, we believe that an increase, as calculated in this manner, cannot be deemed a change in documentation and coding since the analysis only looks at a single set of patient claims, which by definition are coded identically. Analyzing one year of claims is not the correct methodology for determining whether there was a change in documentation and coding practices relative to prior years. Due to this fundamental flaw, the MHA reiterates its prior request that the CMS use medical records data to distinguish documentation and coding changes from real case-mix changes and reduce the documentation and coding offset appropriately. At minimum, the CMS should use a more appropriate methodology to estimate documentation and coding, taking into account real changes in case-mix. The AHA s analysis found a cumulative documentation and coding effect of 3.6 percent for FY 2008 and 2009, compared to the CMS 5.4 percent. In addition, for sole

3 Page 3 of 15 community hospitals and Medicare Dependent hospitals, the CMS stated that total cuts of 5.4 percent and 2.4 percent, respectively are needed. These adjustments are applied on a prospective basis which permanently removes the increased payments from the system. However, the MHA urges the CMS to reconsider its past and proposed cuts to SCHs and MDHs. The CMS should use the methodology described above to re-estimate documentation and coding increases related to SCHs and MDHs and to correct the cuts it has already made, as well as the cuts it proposes to make, accordingly. HOSPITAL READMISSION REDUCTION PROGRAM The Affordable Care Act of 2010 (ACA) mandates that the CMS implement a program beginning in FY 2013 under which hospitals with higher than expected readmission rates would be subject to reduced Medicare payments. In addition, the ACA mandates that payment reductions be based on the number of "excess" readmissions at the hospital, with a cap that would limit penalties in the first year of the program to 1 percent of the hospital's base operating Medicare payments. In the proposed rule, the CMS puts forward the first of a planned two-part regulatory proposal for the readmissions reduction program. In the rule, the CMS discusses the conditions and readmissions to which the program would apply in FY 2013, the measures and methodology used to calculate hospitals readmission rates, and the public reporting of the readmissions data. In the FY 2013 IPPS rule, the CMS plans to propose specific information regarding the payment adjustment. For FY 2013, the CMS proposes to use the three currently reported 30-day readmission measures for heart attack, heart failure and pneumonia patients. The statute mandates that the CMS use measures that are endorsed by the National Quality Forum (NQF). The statute further directs the CMS to exclude from the measures readmissions that are unrelated to the prior discharge, such as planned readmissions and transfers. In interpreting the statutory language, the CMS concludes that the current specifications of the measures fulfill this criterion, and it proposes no further modifications to the measures. The MHA strongly disagrees with the CMS' proposal and believes the agency has ignored Congress' intent that the measures be modified to explicitly exclude unrelated and planned readmissions. As the CMS discusses in the proposed rule, the heart attack readmissions measure excludes planned readmissions for percutaneous transluminal coronary angioplasty and coronary artery bypass graft procedures. The heart failure and pneumonia measures contain no corresponding exceptions. The MHA believes that Congress intended for further refinements to be made to these measures, and that the CMS has failed to comply with that direction. Despite the CMS assertion, we do not believe this small set of existing exclusions meets Congress intent that unrelated readmissions be excluded from the measures. Specifically, the current exclusions are for procedures which are related to the original heart attack admission.

4 Page 4 of 15 As hospitals have reviewed their own readmissions and engaged in efforts to reduce their readmission rates, they identified that there are many reasons why a patient may return to the hospital for a planned admission and that there are also many reasons for readmissions that are unrelated to prior admissions. However, since individual hospitals have access only to records for patients who return to their facility for a readmission, their ability to analyze readmissions is limited because they cannot examine data for patients who seek further care elsewhere. As the CMS has the data necessary to thoroughly analyze all Medicare readmissions, the MHA urges the CMS to conduct a study to determine the common reasons for planned readmissions for heart attack, heart failure, and pneumonia patients and determine a subset of readmissions that are unrelated to a patient s initial admission for the condition. We recognize that conducting a valid readmissions study to identify planned and unrelated readmissions may require several years of work and may not be finalized prior to FY In light of this, we propose several steps that the CMS may take in the interim that could improve on the measures. 1) Always exclude certain patients from the readmission measures. Patients with diagnoses of cancer, trauma, burns, end-stage renal disease, psychiatric disorders, and substance abuse issues, as well as rehabilitation patients, should always be excluded from the readmission measures. Due to the nature of their conditions, these patients are highly likely to return to the hospital for a readmission. 2) Adopt a coding modifier on hospital claims to identify planned readmissions. The CMS should implement a new modifier on the hospital claims form to identify planned readmissions. Hospitals would use the modifier to indicate whether a patient s readmission was a planned hospital stay. 3) Look to existing classification schemes to identify related readmissions. Several existing classification schemes could be used to identify related and unrelated readmissions while the CMS undertakes a more systematic study. The CMS could consider related readmissions to be any readmission for which the patient s primary diagnosis falls within the same MS-DRG or major diagnostic category as the diagnosis for the initial admission. Or, the CMS could look to a classification system developed by the Agency for Healthcare Research and Quality, the clinical classification software, which groups diagnoses and procedure codes into clinically meaningful groups. Currently, the CMS proposes to assess hospital performance on readmissions using a threeyear measurement period--july 1, 2008 through June 30, 2011; however, the agency is still conducting an analysis to determine if a time period shorter than three years could yield reliable data. The MHA believes it is inappropriate for the purposes of this program to assess hospitals on readmissions that occurred during 2008, which is long before this provision was passed in the ACA. As a result, the MHA urges the CMS to shorten this timeframe and include only more recent data.

5 Page 5 of 15 HOSPITAL QUALITY DATA The Deficit Reduction Act of 2005 (DRA) expanded quality reporting requirements for hospitals to be eligible to receive a full market basket update; it also provided the Secretary with the discretion to add quality measures that reflect consensus among affected parties and replace existing quality measures on the basis that they are no longer appropriate. In the proposed rule, the CMS added four new measures to be included for the FY 2014 annual payment determination and 17 measures for the FY 2015 annual payment determination. To receive a full market basket update, hospitals are required to pledge to report data on these and all measures currently included in the pay-for-reporting annual payment update program and pass the established data validation tests. A Vision for the IQR Program The MHA appreciates that the CMS has articulated its principles for selecting measures for the IQR and the hospital value-based purchasing (VBP) programs. These principles reflect practical aspects of quality data reporting, such as attempting to reduce the data collection burden on providers and aligning measures across the Medicare and Medicaid programs. We note that the number of quality measures on which hospitals must report to the CMS is growing rapidly, not only for the inpatient and outpatient quality reporting programs, but for the meaningful use requirements and the voluntary accountable care organization program. To reduce the hospital reporting burden, the MHA urges the CMS to align the measures used for various Medicare programs whenever possible and encourage the CMS to clearly link the selection of measures for the IQR with the framework put forward in the National Quality Strategy. The CMS states that one of the principles for the selection of quality measures is to use, whenever possible, measures that have been endorsed by a multi-stakeholder organization. In this proposed rule, the CMS seeks comment on options through which it may consider using multiple consensus-building entities to assist in the measure development process. The MHA believes those entities should be the National Quality Forum (NQF), the Hospital Quality Alliance (HQA), and when it is fully ready to recommend measures, the Measure Application Partnership (MAP). These three organizations are the primary consensus groups for hospital quality reporting, and the CMS should select for the IQR only measures approved by these organizations. Measure Retirement For FY 2014, the CMS proposes retiring eight measures from the IQR program. The CMS proposes retirement of seven of the measures because hospitals scores on the measures are uniformly high, which the CMS refers to as being topped out. The remaining measure is proposed for retirement since current evidence suggests that there may be negative unintended consequences associated with its use. Consistent with the AHA, the MHA believes careful

6 Page 6 of 15 thought needs to be given to the issue of retiring measures from public reporting, and as a result, the MHA urges the CMS to proceed cautiously. The MHA is concerned that the CMS proposal to retire some of the measures within several long-standing measure sets may be disruptive to quality improvement efforts. Very little research has been done to determine conclusively how quality measurement impacts quality of care and patient outcomes, but the work that has been done to date has shown the importance of having multiple related metrics on which to assess quality of care. The CMS proposal will not materially lessen the reporting burden to providers because hospitals will still be required to report on other measures in the measure sets containing those measures proposed for retirement. As mentioned above, each measure within a set has only a few unique data elements associated with it. Therefore, even with the retirement of some measures, the bulk of data collection will continue to be required for those topic areas. The MHA also is concerned that some of the measures proposed for retirement have been determined to be accountability measures by The Joint Commission. The Joint Commission defines accountability measures as those for which there is a large volume of research linking the measure to improved outcomes; the measure accurately assesses the relevant clinical process; and implementation of the measure has minimal unintended adverse consequences. If these measures have been determined to be clinically meaningful, important for assessing hospital quality and useful for consumers, then they should continue to be used for public reporting. The fact that hospitals scores generally are very high on these measures does not make them less relevant. We appreciate that the CMS recognizes that quality measurement is a dynamic activity, and we agree that there are appropriate circumstances in which measures should be retired, such as when continued use of the measure may have unintended, negative consequences. However, we believe that universally high scores among providers on a particular measure is not by itself a valid justification to cease public reporting of a measure. Consistent with the AHA, the MHA suggests that, as an intermediate step, the CMS not use measures in the hospital VBP program that it determines to be topped out, but that those measures remain in use for the IQR program and continue to be reported on Hospital Compare. In the future, the CMS should assess what impact the retirement of a measure may have on care delivery, hospital reporting burden, and public use of quality information. FY 2014 Proposals for IQR The CMS proposes to add four new measures for the FY 2014 annual payment update determination, with these measures described below. 1. Central Line Insertion Practice Adherence Percentage. This measure would assess adherence to evidence-based practices during the insertion of a central line. The MHA supports the reduction of central line-associated bloodstream infections (CLABSI) as a

7 Page 7 of 15 national patient safety goal, as articulated first in the HHS Action Plan to Prevent Healthcare-Associated Infections, and more recently in the National Quality Strategy and Partnership for Patients initiative. Since January 2011, hospitals have been reporting on CLABSI rates for the IQR and through the National Healthcare Surveillance Network (NHSN) system for the FY 2013 annual payment determination. These measures will soon be reported on Hospital Compare. In this particular instance, because we have a valid and well-constructed outcomes measure, we believe it is not necessary to introduce a process measure on central line insertion practices. This would actually be a step backwards on measuring quality. The CMS has acknowledged it is sensitive to the measurement burden placed on hospitals. The MHA believes the limited resources available within hospitals for quality reporting activities would be better put to use through another measure. Also, we note that CMS appears to have confused two different quality measures in its description of this measure. NQF measure #298 is a measure developed by the Institute for Healthcare Improvement (IHI). It is very similar, but not identical, to a measure assessing central line insertion practices that has been developed by the Centers for Disease Control and Prevention (CDC) for use through the NHSN. The CDC measure is not NQF-endorsed. The IHI measure cannot be collected through the NHSN system. 2. Catheter-Associated Urinary Tract Infection. This measure would assess rates of catheter-associated urinary tract infections (CAUTI). It would be collected through the NHSN system. The MHA supports the use of this measure for implementation in the IQR for the FY 2014 annual payment update. We note, however, that the primary process through which hospitals engaged in the new CUSP: CAUTI project are seeking to reduce CAUTI rates is the expedited removal of urinary catheters, which would decrease the overall number of patient days of catheter use. This measure, however, uses device days as the measure denominator. The use of device days may have the unintended consequence of potentially artificially inflating the urinary tract infection rate as hospitals appropriately remove catheters sooner from less sick patients who no longer need them. The CUSP: CAUTI project is currently testing what effects this may have by collecting data for both device days and patient days. 3. Medicare Spending per Beneficiary. This measure would assess, per hospital, perbeneficiary Medicare parts A and B spending from three days pre-discharge to 90 days post-discharge. Spending would be aggregated at the hospital level. Beneficiaries admitted to a particular hospital would be included in the measure population for that hospital. Spending for a beneficiary would be calculated for a 90-day window postdischarge. All Medicare part A and B payments, including those made by the beneficiary, such as coinsurance and deductibles, would be included in the spending calculations. The CMS notes that transfers, readmissions and additional admissions would be included in the spending episode, but the agency provides no detail on how those costs would be attributed. The CMS proposes to adjust the measure for beneficiary age and severity of illness, as calculated by the hierarchical condition categories (HCCs).

8 Page 8 of 15 The CMS also proposes to exclude spending related to wage index differences, hospitalspecific rates, indirect medical education (IME), and disproportionate share hospital payments in order to standardize for geographic payment and other structural differences. The MHA also suggests that CMS adjust for socioeconomic status, which substantially contributes to cost variation. We are unclear as to what the CMS actually intends to measure with this proposed metric. If the CMS is trying to capture hospital efficiency, then a 90-day time period is much too long. Hospitals have little influence over beneficiary spending on services long after a patient is discharged from the hospital. The MHA urges the CMS to implement a shorter post-discharge time period, such as 15 days, which would be much more appropriate in assessing hospital efficiency. This time period could include quickly occurring readmissions that may be attributed to less than optimal care given during the initial admission. This time period could also include any spending for physician visits after discharge. However, getting patients in to see their physician after discharge is a desirable outcome, so it is unclear how the CMS would enlist hospitals to help ensure that these clinical encounters are realized while penalizing them for having higher spending measure in an efficiency measure. If the CMS intent is to measure general perbeneficiary spending, then a 90-day timeframe may be appropriate, but it should not be attributed to a particular hospital nor triggered by a beneficiary s inpatient stay. The MHA requests that the CMS clarify how it plans to include transfers, readmissions and additional admissions into the measure. For example, would a patient who is transferred during an inpatient stay be assigned to the first hospital or the second hospital? If a patient was readmitted during the 90-day hospital to a different hospital, how would the spending for that readmission be assigned? 4. Participation in a Systematic Clinical Database Registry for General Surgery. The proposed structural measure of participation in a systematic clinical database registry for general surgery collects data solely on whether or not a hospital participates in a registry. This measure should not be included in the IQR program because it is neither tightly linked to improving quality and patient care, nor has it been endorsed by the NQF nor adopted by the HQA. For many of the pay-for-reporting measures, there is a great deal of scientific evidence that providing that particular process of care can improve patient outcomes. The structural clinical registry participation measure fails to meet that standard. There is no established connection between whether a hospital answers yes or no to a registry participation measure and the quality of the care that hospital provides. In addition, the MHA requests the CMS to clarify a discrepancy in the rule regarding the timeframe for the reporting of this measure. On page 25898, the CMS states that hospitals would report on this measure in July 2012 for the FY 2014 payment update. Yet, on page 25919, the CMS states that reporting on all structural measures for the FY

9 Page 9 of update would occur between April 1, 2012 and May 15, The MHA respectfully requests clarification of the reporting timeframe. FY 2015 Proposals for IQR The CMS proposes to add 17 new measures for the FY 2015 annual payment update determination. Healthcare-Associated Infection Measures. The CMS proposes to add three measures of healthcare-associated infection, all collected through the NHSN system, to the IQR program for the FY 2015 annual payment update determination. These measures include methicillin-resistant staphylococcus aureus (MRSA) bacteremia rates, Clostridium difficile standardized infection ratio, and health care personnel influenza vaccination rates. The MHA does not support the use of these measures for the FY 2015 annual payment update determination. We believe these measures need further refinement before they are included in the IQR. With regards to promoting health care worker influenza vaccinations, evidence has emerged over the past few years clearly indicating that health care workers can unintentionally expose patients to seasonal influenza if they (the workers) have not been vaccinated, and such exposure can be dangerous to vulnerable patients. To protect the lives and welfare of patients and employees, the MHA supports mandatory patient safety policies that require either influenza vaccination or wearing a mask in the presence of patients across health care settings during flu season. We support the public reporting of health care worker vaccination rates; however, we are concerned that requiring the collection of this information through NHSN is redundant and labor intensive. The current specifications of the NHSN system require hospitals to submit detailed data on every employee, rather than aggregated data on vaccination rates. This is largely the reason why currently only a very few hospitals submit this information voluntarily through NHSN. The time and resources that would be required to collect the detailed information specified in NHSN would be enormously burdensome and labor intensive. To ensure that health care workers receive their vaccinations, most hospitals already have a database to record the vaccinations for tracking purposes. Requiring hospitals to repeat this data entry into NHSN is redundant. We understand that CDC is looking to develop the ability for hospitals to submit summary data on health care worker immunization rates. While we fully support public reporting of this information, we suggest that CMS postpone incorporation of this measure into the IQR until the CDC has completed and fully tested the summary data collection tool, or CMS identifies an alternative NQF-endorsed measure that may be used to collect this information. Stroke Measure Set. The CMS proposes to add eight measures of stroke care. The MHA supports inclusion of these measures into the IQR program for the FY 2015 annual payment update determination with some modifications to the CMS proposed data collection process. These measures are NQF-endorsed and HQA-adopted and in use by The Joint Commission as a core measure set. They already are in use in an e-specified format for the Medicare electronic health record (EHR) incentives program meaningful use criteria. The CMS

10 Page 10 of 15 proposes to collect these measures through manual data abstraction for the IQR program and as EHR-generated data for the Medicare EHR incentives program. Requiring hospitals to submit data on the same measures twice, through two different data collection mechanisms, is duplicative and unduly burdensome for hospitals. It has been identified that errors exist in the e- specifications for these measures. As a result, the MHA urges the CMS to correct the e- specifications and encourage the CMS to conduct a comparison of data collected through manual abstraction and data derived through EHR-based reporting for the stroke measures. Once these steps have been completed, the MHA encourages the CMS to determine an optional process whereby hospitals may use their meaningful use data submission towards the fulfillment of the IQR program requirements. Venous Thromboembolism (VTE) Measure Set. The CMS proposes to add six measures of VTE prevention and care. These measures are NQF-endorsed and HQA-adopted and in use by The Joint Commission as a core measure set. Our comments on the VTE measures mirror our thoughts on the stroke measures, with the MHA supporting inclusion of these measures into the IQR program for the FY 2015 annual payment update determination with some modifications to the CMS proposed data collection process. Specifically, the CMS should correct the e-specifications and conduct a comparison of data collected through manual abstraction and data derived through EHR-based reporting for the VTE measures. Once these steps have been completed, the agency should determine an optional process whereby hospitals may use their meaningful use data submission towards the fulfillment of the IQR program requirements. Timing of Transition to EHR-Based Data Collection for the IQR. In the proposed rule, the CMS seeks comment on when hospitals will be ready to transition to EHR-based data collection and submission and suggests that 2015 may be an appropriate year. However, the MHA does not believe that enough progress will be made in this regard to expect universal data collection through EHRs by 2015 for the IQR program. Hospitals share the CMS goal of ultimately collecting and submitting quality measures information through EHRs and such a transition should allow for more information to flow with less data collection burden. However, hospitals have informed us that the collection and submission of the clinical quality measures have been one of the most challenging aspects of meeting the stage I meaningful use criteria. EHR software vendors too have been challenged to build out the reporting software for the clinical quality measures, particularly as this first version of the e-specifications of the measures has been fraught with errors. As stated above, we support the goal of moving toward robust EHR-based data collection. However, we believe it is inappropriate to set a deadline for that transition for all hospitals. We suggest that the CMS look to hospitals success at meeting the meaningful use criteria over the next several years to better gauge the field s and their vendors ability to move toward universal EHR-based data collection. We look forward to commenting on future proposals for this transition.

11 Page 11 of 15 Form, Manner and Timing of Quality Data Submission. The CMS proposes reducing the data submission time period to allow for a to-be-determined data correction period. Rather than 135 days, the data submission period would be 104 days. Likewise, the time allotted for hospitals to submit their population and sample size information would be reduced from four months to three months, and the HCAHPS data submission time period would be reduced from about 14 weeks to about 13 weeks. The MHA appreciates the CMS proposal to develop a data correction period. However, the MHA opposes the shorter timeframes proposed by the CMS due to the increased administrative burden that this would create for hospitals. DRGS: HOSPITAL-ACQUIRED CONDITIONS The DRA required the CMS to identify, by Oct. 1, 2007, at least two preventable complications of care that could cause patients to be assigned to an MS-DRG with a CC or MCC. The conditions must be either high-cost or high-volume or both, result in the assignment of a case to an MS-DRG that has a higher payment when present as a secondary diagnosis, and be reasonably preventable through the application of evidence-based guidelines. The DRA mandated that for discharges occurring on or after Oct. 1, 2008, the presence of one or more of these preventable conditions would not lead to the patient being assigned to a higher-paying DRG. In the FY 2008 inpatient PPS final rule, the CMS adopted eight conditions for which it would no longer pay a higher MS-DRG rate if the conditions were not present on admission. In the FY 2009 rule, the CMS selected two additional hospital-acquired conditions (HACs) and expanded one of the original categories. In the FY 2012 proposed rule, the CMS proposes to add one new condition, contrastinduced acute kidney injury, and five new ICD-9 codes to three of the current HAC categories. The MHA agrees that the addition of the five new ICD-9 codes to the existing HAC categories is appropriate. However, we oppose the CMS proposal to add contrast-induced acute kidney injury as a HAC. The CMS definition would mean that any patient discharged under a code for acute kidney failure (584.9) who received any kind of kidney scan or other contrast will be assumed to have contrast-induced acute kidney injury. However, this cannot be determined simply from the presence of these codes on a claim. Just because a patient has had a procedure with contrast does not mean that there is an automatic linkage that the contrast is the cause of the kidney problem. For example, patients who develop acute renal failure due to pyelonephritis, sepsis or a renal infarct and who had a renal computed tomography (CT) scan would be included in the HAC population. The CMS assumption is that the scan caused the renal injury, when it may have been the other way around the renal injury may have prompted the scan. Further, our understanding is that acute kidney injury may be a temporary condition, and could be due to many different causes including dehydration, urinary tract obstruction (including benign prostatic hypertrophy) and low blood volume, among other reasons.

12 Page 12 of 15 In addition, the AHA has identified coding challenges that would limit the adoption of this HAC. Hospital coding procedures vary there is no requirement that hospitals assign codes for minor procedures. Some hospitals internal coding policies instruct staff to assign codes for procedures that are considered minor, diagnostic or that don t affect the MS-DRG, while other hospitals policies do not. In addition, some hospitals policies will include coding for any procedures that require contrast or an injection, but others will code only those procedures that affect the MS-DRG. Procedures like arteriograms, phlebographies, CT scan of the kidney and pyelograms do not affect the DRG and would not be captured. HOSPITAL VALUE-BASED PURCHASING PROGRAM In late April, the CMS released a final rule to implement the hospital value-based purchasing (VBP) program, which will begin in FY In that rule, the CMS finalized the set of measures that would be used in FY 2013, as well as the initial measure set for FY 2014, established the FY 2013 performance standards, and outlined how hospitals VBP scores would be calculated. In the FY 2012 inpatient PPS proposed rule, the CMS proposes to add the total Medicare spending per beneficiary measure discussed in the quality reporting section above to the VBP program beginning in FY The CMS proposes that this measure have a ninemonth baseline period from May 15, 2010 through Feb. 14, 2011 and a nine-month performance period from May 15, 2012 through Feb. 14, The CMS would score each hospital on its achievement and improvement on the measure much like it outlined in the VBP proposed rule for the clinical process measures. The CMS proposes to include the spending measure in a separate "efficiency" domain when determining hospitals' overall VBP scores. The ACA mandates that measures selected for the VBP program be included on the Hospital Compare website for at least one year prior to the beginning of the performance period for the fiscal year for which the measure is being added. The CMS proposes that the FY 2014 performance period for the efficiency measure would begin on May 15, In order to fulfill its statutory obligations, the CMS would have to have posted hospitals performance on this measure on Hospital Compare by May 15, We are unaware of any such posted information. Therefore, the CMS cannot finalize its proposed performance period. The MHA urges the CMS to propose a new performance period that is consistent with statutory requirements. In its discussion of how it would score hospitals on the efficiency measure, we note that the formulas put forward by the CMS in the rule are incorrect. For the efficiency measure, unlike other measures in the VBP program, lower scores indicate better performance. The equations that the CMS has included in the rule are identical to those established for the clinical process measures, measures for which higher scores indicate better performance. We ask the CMS to correct the equations to reflect this in the final rule. We note that the examples of the calculations included in the proposed rule are correct. In addition, the CMS puts forth a proposal that, in the future, it will generally add measures to the VBP program at the same time it adds them to the IQR program. Again, this is

13 Page 13 of 15 inconsistent with the statute. The CMS cannot take this action while fulfilling its obligations under the ACA, which require it to only include measures in the VBP program that have also been included on the Hospital Compare website for at least one year prior to the beginning of the VBP performance period. In addition, in the VBP final rule, the CMS established that the performance period for the eight HAC measures will begin on March 3, 2012, which the CMS states is one year after the measures were first displayed on Hospital Compare. However, the measures were not displayed on March 3, The HAC measures were first displayed on the CMS website (www.cms.gov) on March 31, 2011 and on Hospital Compare on April 21, The MHA urges the CMS to correct this error in the inpatient PPS final rule or outpatient PPS proposed rule and revise the start of the HAC performance period to April 21, WAGE INDEX Allowable Pension Cost for the Medicare Wage Index The CMS proposes to revise its policy for determining pension costs for Medicare wageindex purposes. Specifically, the CMS proposes to generally maintain the current requirement that pension costs must be funded to be includable and that all hospitals must report actual pension contributions funded during the reporting period on a cash basis. In addition, the CMS proposes to include pension costs equal to the hospital s average actual cash contributions to the defined-benefit pension plan over a three-year period. This three-year average would then be used as the hospital's includable pension cost for purposes of determining the Medicare area wage index in FY 2013 and beyond. Since the hospital wage index is a relative measure of wages rather than an absolute measure, it is critical that hospitals and Medicare use consistent definitions, methodologies, rules and interpretations for the acquisition and application of wage data. We are aware of instances in the past of much variation in the treatment of cost among hospitals, depending upon fiscal intermediary staff, etc. Under the latest CMS proposal, hospitals would continue to be treated inconsistently. Certain hospitals may have overfunded or "pre-funded" pension plans as of the start of the three-year rolling average contribution methodology. However, the proposed methodology does not include such prefunded amounts in the wage index calculations. As a result, hospitals with pre-funded pension plans would have individual hospital wage indices that were, and would continue to be, understated over the life of the plan. In contrast, hospitals that have underfunded pension plans as of the start of the proposed methodology would have individual hospital wage indices that were, and would continue to be, overstated over the life of the plan. Policies that systematically understate the wages of certain hospitals while overstating the wages of others are not appropriate. Since changes to the wage index are budget neutral on a national basis, the MHA urges the CMS to ensure that the policy changes it implements are appropriate and fair to all hospitals. Therefore, the MHA urges the CMS to delay this proposed change and instead create a

14 Page 14 of 15 Medicare Technical Advisory Group (MTAG) charged with making recommendations on the most appropriate way to determine the pension costs that should be included in the wage index. This would allow the CMS to obtain input from the hospital field on a very technical issue, which we believe is extremely important. After consultation with the MTAG, the agency should propose a methodology that accurately reflects the total resources hospitals expend over the life of their defined-benefit pension plans and recognizes those costs fully in the wage index. Lastly, if the CMS opts not to delay the change and create an MTAG, the CMS must consider the impact of having policies that vary from year to year. The CMS should true-up costs so that any policy revisions result in hospital wages being accurately and consistently reflected on both an absolute and a relative basis. REPORTING REQUIREMENTS FOR PENSION COSTS FOR MEDICARE COST- FINDING PURPOSES In addition to the proposed changes for wage-index purposes described above, the CMS also proposes to revise its policy for determining pension costs for Medicare cost-finding purposes. Specifically, the CMS proposes to continue requiring pension costs to be funded in order to be reportable and to continue to limit the current period liability for pension costs (i.e., maximum annual allowable pension costs). In addition, for cost-reporting periods beginning on or after Oct. 1, 2011, the CMS proposes to change the methodology for calculating the limit on the current period liability by setting the limit at 150 percent of the average of the three consecutive reporting periods out of the five most recent periods which produce the highest average. In addition, the CMS proposes to make certain exceptions to this policy available. Before changing its policies for determining pension costs for Medicare cost-finding purposes, we suggest that the CMS do as requested above: convene an MTAG and establish a policy on the most appropriate way to determine the pension costs that should be included in the wage index. After this policy has been established, the CMS should propose a cost-finding methodology that compliments the wage-index methodology. For example, it is possible that the CMS will, after seeking input from an MTAG group, recommend that hospitals recognize Generally Accepted Accounting Principles (GAAP) as the appropriate methodology for determining pension costs for Medicare wage-index purposes. In that case, for cost-finding purposes, it might be more appropriate to include GAAP pension expenses if funded during the year, or within a 12-month period after year end, and consider any needed modifiers that might be caused by either underfunded or overfunded plans coming into the cost-finding policy. HOSPITAL SERVICES FURNISHED UNDER ARRANGEMENTS The CMS proposes to modify the Provider Reimbursement Manual to clarify which inpatient services a hospital may provide under arrangements. The CMS believes some providers have incorrectly interpreted the instructions to mean that even routine services

15 Page 15 of 15 consisting of bed and board, or nursing services and other related services, use of hospital facilities, and medical social services may be provided under arrangements. The CMS proposes to consider routine services, if provided in the hospital, as being provided by the hospital not under arrangement. If services are provided outside the hospital, they will be considered as being provided under arrangement and not by the hospital. The MHA is concerned about the CMS proposal since the CMS has implicitly and explicitly recognized, its proposal is not mandated by either statute or regulations. Rather, the entire basis for the CMS proposal is that certain statutory language suggests that the hospital is required to exercise professional responsibility over the arranged-for services. The MHA believes that a change in long-standing agency policy should be based upon more than a suggested reading of statutory language; yet the CMS offers no policy rationale to support the proposed change. The CMS has not indicated that there has been any inappropriate behavior by hospitals furnishing inpatient services under arrangements, and CMS has, for years, had in place oversight and enforcement mechanisms to ensure that the under-arrangements model is not abused. Further, the proposed policy is contrary to the agency s increasing emphasis on care coordination and service delivery models that reduce costs. It takes away an established mechanism for furnishing hospital services that ensures patients are receiving high-quality care, while at the same time maximizing efficiencies. In sum, the CMS has both implicitly and explicitly approved the under-arrangements model for furnishing inpatient hospital services for many years. Changing it now would be costly and disruptive to hospitals that operate under models that would be prohibited under the new policy. Because the CMS has not identified any compelling need to change its policy, the MHA urges that CMS not finalize its proposal. If, however, the CMS decides to adopt its proposal, it is imperative that the agency allow hospitals that have been using the under-arrangements model for furnishing inpatient hospital services to continue to do so. Again, the MHA appreciates this opportunity to provide comments to the CMS regarding this proposed inpatient rule and urge you to please take them into consideration. We believe our suggested modifications will result in positive changes for hospitals and the Medicare beneficiaries they serve. If you have questions on this comment letter, please contact me at (517) or Sincerely, Marilyn Litka-Klein Vice President, Health Finance Policy and Health Delivery

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